By typing your name you attest that you are the person filling out this form and this acts as your signature

First Name

Last Name

Assignment of Benefits *

I hereby assign all rights, privileges and remedies to payment for health care services to Tyner Physical Therapy. I also authorize Meg Tyner PT, DPT, ATC, CSCS having treated me, to release to government agencies, insurance carriers and all others who are financially liable for my care, all information needed to substantiate payments for care and to permit representatives thereof to examine and make copies of all records relating to such care and treatment. I have read and understand the privacy practices of the office.

I Agree

Notice Of Privacy Acts *

Checking this box below indicates that you have received a copy of Tyner Physical Therapy’s Notice of Privacy Practices on the date indicated.

Yes

Billing and Cancellation policies *

Checking the box below indicates that you agree to the terms:
• Payment of all co pays is expected at the time of service or at the end of the week if you come for multiple treatments per week.
• Fee for service is $125. In the event that your insurance does not cover this fee the responsible financial dependent will be responsible to cover the FULL fee for service.
• A scheduled appointment must be cancelled at least 24 hours in advance or a $75 cancellation fee will be assessed. Similarly, if you do not show up for an appointment the $75 cancellation fee will also apply. The fee is not waived for business or travel and is not billable to any insurance carrier.

I Agree

Credit Card Number *

CCV *

Expiration Date *

Thank you!

No referral or prescriptions needed here!

All you need to do is make an appointment and walk in the door to begin the the path towards improving your health – we’ll handle the rest. We will work with most major insurances out of network and submit the claims on your behalf so you can spend your time getting better, not on paperwork. The most common plans include:

Aetna PPO & POS

Cigna PPO & POS

BCBS PPO & POS

United Healthcare PPO

For patients without out of network benefits, sessions are available in affordable payment plans. Getting your body to feel better is not only important physically, but it’s vital to keeping a mental balance. One visit with us and you’ll feel the difference between us and those insurance-based clinics.